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Delay in Transporting Some Trauma Patients Linked to In-Hospital Mortality

 |  By cclark@healthleadersmedia.com  
   November 15, 2012

For patients with serious penetrating trauma injuries, emergency medical transport teams should "scoop and go" rather than "stay and stabilize" the patient because staying at the scene for 20 minutes or more increases the patient's chance of in-hospital death.

That's the conclusion of a study in the Annals of Emergency Medicine based on a 14-year project that tracked 19,167 trauma patients treated at the University of California Irvine Medical Center, 865 of whom died.

"If the paramedics stay on the scene longer than 20 minutes, you'll start to see an increase in mortality," explains C. Eric McCoy, MD, UC Irvine's base hospital medical director and principal author of the study. 

He says that it doesn't matter how long it takes for the ambulance to transport the patient to the hospital, it's just important that emergency responders move the patient from the scene of the incident as soon as possible.

It also doesn't matter if the ambulance must travel a longer distance, bypassing non-trauma hospitals to go to a trauma center. The important thing is to minimize the time in the field, at the scene.

The finding may be controversial, because a decision to transport rather than waiting to stabilize patients may result in faster ambulance speeds and an increase in collisions. But based on this research project, there's a statistically significant benefit in reduced mortality if patients are quickly transported, McCoy says.

He stressed that the finding only proved true for a minority of the traumatic injuries—those involving penetrating wounds such as stabbings or gunshot injuries, which were about 16% or 2,997 of the 19,167 trauma patients transported—not blunt force injuries such as falls or injuries from vehicle accidents. It also was only true for his hospital, a Level 1 trauma center in Orange County, CA, which is a largely urban area. 

McCoy says he does not know whether the findings would translate to a rural setting.

He also cautioned that the study is only the first of its kind, and "will not change the entire paramedic practice," which varies widely around the country. "We will need further studies to corroborate or refute our findings."

Another aspect of the issue that could not be verified by McCoy's project is whether the findings hold true for mortality after patients are discharged from the hospital, perhaps to a skilled nursing care or hospice setting. The research was only able to review in-hospital death rates.

"We're just at the early stage," he says.  "A long time ago, we didn't really know that heart patients benefitted from timely response times or chest compressions. It was only after researchers studied populations that they could separate out which patients benefitted from immediate care, and that's where we're at with this."

Another issue for health policy makers, hospitals, physicians and emergency response teams is the varying structure of 911 response teams, which may be owned or operated by private for-profit or non-profit organizations, municipal governments or counties, and not hospitals. 

In those different organizational structures, resource and personnel variation may influence response times that could turn the data upside down. It's important for EMS systems, with their base hospital collaborators, to identify patients that may be helped by more rapid transport.

"In particular," the report says, "scene time (time spent treating the patient at the scene prior to transport) is the out-of-hospital interval that EMS systems have the most power to control, given that this interval is composed of evaluation and management that is guided by local EMS policy, procedures and protocols."

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